Resident #70 fled the facility's mental health unit at 5:45 PM. Staff searched but couldn't determine which direction he had gone because "Resident #70 was fast and ran out of their site," according to the Director of Nursing.
The patient was discovered at 6:45 PM hiding in bushes approximately 50 feet behind the building. Emergency Medical Services evaluated him at 6:50 PM, and he returned to the facility at 7:15 PM with no injuries noted.
Licensed Practical Nurse #212, who was working the mental health unit that evening, confirmed the resident "had tried to leave the facility multiple times during the day on 08/11/25." Despite these repeated escape attempts throughout the day, the facility maintained only basic interventions.
"The interventions in place at the time of Resident #70's elopement was for staff to provide redirection and for staff to keep a close eye on him," LPN #212 told federal inspectors during a September 29 interview.
The resident was not placed on one-on-one supervision until after his successful escape and return to the facility. Both the Director of Nursing and LPN #212 confirmed this timing during separate interviews with investigators.
The Administrator and Director of Nursing acknowledged that Resident #70 was on "frequent staff checks" due to his "increase in behaviors" but maintained this level of monitoring even as escape attempts escalated throughout the day.
Staff completed a skin assessment after the resident's return, finding no injuries and no complaints of pain. He was placed on one-on-one supervision at 7:15 PM and discharged to a behavioral hospital around 3:00 AM on August 12.
The facility's elopement policy addressed only the procedures to follow after a resident escapes, according to the Administrator. The policy apparently provided no guidance for preventing elopements when residents demonstrate escalating attempts to leave.
Federal inspectors reviewed the facility's internal timeline documenting the incident. The timeline showed the one-hour gap between the resident's escape at 5:45 PM and his discovery at 6:45 PM, during which staff were unable to locate him despite searching the grounds.
The case represents a breakdown in the facility's supervision protocols for vulnerable mental health patients. While the resident suffered no physical injuries during his time hiding outdoors, the incident exposed gaps in the facility's ability to protect patients who repeatedly attempt to leave.
Resident #70's successful escape came after what staff described as multiple failed attempts throughout August 11. The escalation from repeated redirection needs to an actual elopement suggests the facility's intervention strategies were inadequate for his level of risk.
The timing of his eventual transfer to a behavioral hospital, occurring just hours after his return from hiding in the bushes, underscores the severity of his mental health crisis that day. Staff had been managing his "increase in behaviors" with frequent checks rather than continuous supervision.
Federal regulations require nursing homes to provide adequate supervision to prevent residents from wandering or leaving the facility unsupervised when such departure would pose a risk to their health or safety.
The inspection was conducted in response to a complaint filed under number 2574379. The deficiency was classified as having caused minimal harm or potential for actual harm, affecting few residents.
The violation occurred in the facility's mental health unit, where patients typically require enhanced supervision due to their psychiatric conditions and potential for unpredictable behavior.
New Lebanon Rehabilitation and Healthcare Center must submit a plan of correction addressing how it will prevent similar elopements and ensure appropriate supervision levels for mental health patients who demonstrate escape behaviors.
The resident's case illustrates the challenge nursing homes face in balancing patient autonomy with safety requirements, particularly for individuals experiencing acute mental health episodes that drive them to repeatedly attempt leaving the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Lebanon Rehabilitation and Healthcare Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
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